Dilemma comes to end

In the last decade, senior management in healthcare (voluntary or mandatory) implemented quality concepts in their facilities due to many reasons including globalisation, industry competitiveness, customers demand, emergence of social media, resources brain drain, and regulations became more robust, in order to achieve better health care outcomes.

On their strategic radar, the use of different accreditation or certification models as an approach to improve healthcare services, operations and outcomes was the catalyst that would solve all problems and gain the blessing of the stockholder. Therefore, one can notice a tenfold increase in the number of healthcare facilities obtaining different types of accreditation and/or certification over the last 15 years such as different ISO certifications, Joint Commission International (JCI) accreditation, Canadian accreditation, Australian accreditation, College of American Pathologist (CAP) accreditation, American Association of Blood Bank accreditation and recently local Central Board for Accrediting Healthcare Institutions (CBAHI) etc. To some extent it became an accreditation marathon where you may find a healthcare facility that has a boutique of different types of accreditations.

This approach put the executive management in a very difficult situation to balance between the pressure coming from the stakeholder to deliver high strategic outcomes and the extra burden on the operational budget. Executives assumed many unnecessary and exhausting additional expenses of quality deployment due to accreditation such as creating new quality positions, extra labour works, overtime, extra supplies, facility upgrades, renovation, processes redesign, acquiring new equipment, third party testing, mock inspections and the list goes on and on in order to meet accrediting bodies’ requirements. This created a negative impression among executives and doctors claiming that quality deployment is draining the budget, is labour intensive, and hence accreditation is a redundant practice and impractical in advancing medical treatments and services. In addition, chief financial officers and financial department did not buy-in into quality and were totally under the impression that quality is a draining cost centre with zero profit when compared to the return on investment (ROI).

On the other hand, many studies and surveys showed that patients and their families did not express the utmost satisfaction in accredited hospitals aside from knowing their rights in these hospitals and hence the complaints increased over the years. Despite the extensive training on quality improvement methodologies such as quality tools, root-cause-analysis (RCA), risk management, six-sigma, balance score cards (BSC), change management, key performance indicators (KPI) to different disciplines and levels of healthcare workforce, the buy-in in deploying quality tools as routine practice is very marginal if not only detained in the quality department and among those who want to work in quality improvement projects for the sake of publication.

No one can doubt the importance of quality concept implantation in healthcare nor argue about the value of accreditations in discovering the gaps in healthcare services and improving processes but the only attribute that led to this situation, in my opinion, is the lack of understanding and implementing of quality cost programmes to reduce operating expenses and/or increase productivity, efficiency and revenue in healthcare services. Even though quality directors and managers view quality as the prime goal for services improvement in healthcare, in my opinion, they failed in highlighting the importance of using quality cost system to organisation leadership to gain their buy-in and produce a tangible outcome of the routine quality practice.

Upon personally reviewing many quality programmes across healthcare facilities in the last 15 years, I could not find a link between the quality implementation programme and quality cost programme nor a single quality manger working closely with a functional manger and coordinating with the finance department to report quality costs to executive management in order to measure the level of improvement and make informative decisions.

The main focus of quality units is about proactive or reactive assumptions on how to meet accrediting bodies’ requirements and standards without taking into consideration the quality cost programme but accreditation expenditures. In my opinion, the lack of knowledge and expertise among quality, functional and finance professionals in deploying quality costing system in healthcare services have negatively impacted the development of quality concept over the last decade. This scenario will come to an end with the management style transformation, which is taking place today due to the new certainty of economic diversion and in moving towards project management style in healthcare in the region. There is a need for new set of skills to be learned by quality professionals by looking in-depth into the healthcare operations and fully understanding the iceberg of measured and hidden quality costs. 

What are quality costs and categories?

Understanding the cost of quality is one of the oldest quality business methods. The root goes back to 1951, when Dr. Joseph M. Juran’s first Quality Control Handbook made the analogy of “gold in the mine” That is, there are often hidden costs we cannot see but which can be recovered. Other publications adding to an understanding of quality costs included Dr. Armand V. Feigenbaum’s book, Total Quality Control. Quality costs are the costs connected with both attaining and missing the desired level of quality in a service or product. They may be seen as the costs of preventing quality problems, measuring quality levels, monitoring and/or inspecting quality level or failing to accomplish the desired quality levels.

Over the last several decades, quality costs have been divided into several categories but the most commonly accepted and comprehensive classification have categorised them as 1) prevention, 2) appraisal 3) internal failure and 4) external failure. The detailed definition of each category is:

Prevention costs – Costs of all activities specifically designed to prevent poor quality in products or services. Examples are the costs of new service review, quality planning, supplier capability surveys, process capability evaluations, quality improvement team meetings, quality improvement projects, quality education and training.

Appraisal costs – Costs associated with measuring, evaluation, or auditing product or service to assure conformance to quality standards and performance requirements. These include the costs of incoming and inspection/test of purchased materials, accreditation, services audits, commissioning tests, verification and validation, and calibration of measuring and test equipment, and cost of associated supplies and materials.

Internal failure costs – Failure costs occurring prior to delivery or shipment of the product, or the furnishing of service, to the customer. Examples are the costs of scrap, rework, rescheduling, reinspection, retesting, material review, snag list, and downgrading.

External failure costs – Failure costs occurring after delivery or shipment of the product, and during or after furnishing of a service, to the customer. Examples are costs of processing customer complaints, warranty claims, product recalls, medical errors, fines, readmission, compensations, and hospital acquired infections.

The total of these costs defines quality costs in the broadest sense. There are 75 elements of these categories and the total list of potential quality costs can be exhaustive and create its own financial exercise. It is recommended that when establishing a quality cost tracking system, the implementer use the Pareto chart to identify the highest loss contributors to improve them and as the improvement diminishes, add the secondary quality costs and repeat the improvement process.

Quality costs are the costs connected with both attaining and missing the desired level of quality in a service or product. 

The aim of a quality cost system

The principal idea behind cost of quality systems is the largest and highest quality costs occur after a service has been performed, that is, external failure costs. Altering activities and focusing efforts so that quality issues are identified in progressively earlier stages of internal failure, appraisal and prevention will reduce overall organisational costs. Reducing quality costs is also considered an effective way to regain margin. A second idea is that while external failure costs are often larger than costs created earlier in the flow, they can be also be harder to measure or link to casual events. 

Medications returns complaints, for example, are usually easy to measure, but it may be difficult to identify how the problem found by a patient and paid for in a compensation claim was caused in the drugs’ preparation and dispensing process. In addition, costs due to lost trust are very difficult to quantify. One approach is to start with those internal failure costs which can be identified and tie to specific work activities because in most cases, the roots that underlie these internal failure cost-generating activities are tied to those much larger external failure costs. So, by eliminating the root cause internally, all quality costs are reduced. Installing and using a quality cost programme will allow leadership to make a guided transition from an organisation’s current operational costs to a state of minimal quality costs. The cost of quality for a given issue grows larger as the services moved toward the customer. From service design, setup, delivery, completion, and finally to possible litigation, each step can result in a tenfold increase in quality costs. Not all issues make it to the last stage, but all increase in cost as they move forward.

Improving the bottom line is the goal. A properly understood and managed quality cost programme will aid organisations in realising cost savings while avoiding some of the serious pitfalls that can accompany cost cutting: decrease in service quality, increased patient dissatisfaction, added rework costs, or complaints handling.

The role of accounting and the management of quality costs – focus on the positive

Establishing a quality cost system usually does not require extensive accounting system changes. Access to detailed data currently available may provide enough information to set up a quality cost programme. The key to an effective system is to strike a balance between practicality and comprehensiveness. However, if the larger elements of quality cost are not identified by the existing accounting system, some form of estimation may be needed at first. The critical need is to make sure that the quality cost data makes sense to management, that is, it covers all the known and/or expected sources of quality cost.

During the setup of a quality cost system there may be a need to do some trials to establish the key sources. However, a successful cost of quality programme should be comprehensive and not just cover those portions of the business or cost centres that are simple or obvious. Leaving out portions that are significant but difficult to obtain will skew the decisions and approaches taken to reduce costs. The cost of quality approach and its measurements should be viewed as behaviour modification tools. The goal is to change the behaviour of the organisation’s employees as a group. What senior management expects from an accounting team are reports that measure the totality of costs within a particular area that can have significant impact on operational decisions but not a comprehensive accounting measure. It is important to emphasise to everyone involved that isn’t just a measurement exercise. In the words of Taiichi Ohno, “Costs do not exist to be calculated. Costs exist to be reduced.”

All of the previous discussion indicates a major role in the quality cost system for the accounting office, which is totally missing from the equation of quality cost programmes implementation in current healthcare organisations that strive to achieve high quality services. While the accounting department may not at first wish to accept this task eagerly taking into consideration the misconception that quality improvement is the central function of quality department, but the concept of linking quality measurements to cost does fit within the normal practice of using costs as primary decision drivers. It is hard to argue against the concept of reducing cost while at the same time improving quality especially in the private healthcare sector where each spent dollar counts. To some extent private healthcare sector may recognise the importance of quality cost system but the accounting systems in these organisations are antiquated to optimise its benefit and the quality department don’t push for it due to lack of knowledge. In the public sector, quality cost system never existed because healthcare budget is allocated by the government and quality improvement was a mandate. Efforts were concentrated to improving quality in general under the impression that by embedding quality tools, practice and/or champions in every functional unit in healthcare may act as integral part of errors prevention and cost saving. This approach made quality sound redundant and overlooked quality cost as a powerful tool in healthcare for many years.

This picture has changed in recent years with the Kingdom’s Vision 2030 and the paradigm shift in economic diversity toward services industry and the classic management style has transformed into a modern project management style where costing is a cornerstone in projects’ life cycle and success. Therefore, the quality cost programme will establish its footprint in the upcoming years and is expected to be the main drive for decision making in the right direction.

Quality management often has a negative connotation. Service quality is seen as a good thing, but the management of quality too often focuses on where it is not: on the mistakes, not the successes. In the same vein, views of quality costs within the organisation may focus on negative issues. Some department managers view quality costs as a measure of their department’s mistakes. To counter this view, focus on the positive aspects of quality cost measurement. By helping to reduce overall organisational costs, a department not only makes the organisation more successful, it may also save jobs and therefore retain talent. But to do this, departments must work together and healthcare providers within these departments should uphold the ownership of costs reduction and be empowered by the leadership to foster the organisational culture toward costs reduction and increase revenue.

In conclusion, quality cost programmes are becoming evident as best practices to reduce waste in healthcare services and to be implemented in many functional units in hospitals including laboratories, pharmacies, imaging department, admissions, patient relation, bed management, emergency and other areas where quality cost may have huge positive impacts on the performances and outcomes of these units. Finally, executive management needs to understand the importance of quality cost programmes in running modern healthcare services and quality directors and managers, and the accounting team need to develop new set of skills  to coordinate together and develop their employees to implement the most suitable quality cost programme that fit in their functional units and accounting system.

References available on request.

Across the globe, adverse events associated with medical devices are on the rise. Here are the top five reasons why:

Sheer numbers

Medical device volumes are exploding globally. According to KPMG, the global medical device market will grow from US$483 billion in 2020 to US$795 billion in 2030, a 5.2 per cent CAGR. The major growth drivers are healthcare spending, ageing populations, chronic disease and technological development. More devices and more patients in developed and developing countries mean increased numbers of adverse events – more injuries, more complications and more deaths.

For medical device manufacturers, the costs of quality events are sizeable. According to McKinsey, it is as much as 7 per cent of revenues annually, or over US$35 billion globally.

According to KPMG, the global medical device market will grow from US$483 billion in 2020 to US$795 billion in 2030, a 5.2 per cent CAGR.

The double-edged sword of innovation

Technology advances also introduce risks. The pace of innovation in medical devices is breath-taking – novel in-vitro diagnostics, drug-device combinations, next generation materials such as graphene and bio-substrates, 3D and 4D printed instruments and implants, nano-scale robotics, IOT sensors, and software as a medical device. With such dramatic innovation in diagnostics and therapeutics comes uncertainty and risk.

Industry sources estimate 15 per cent of devices are connected. These devices are also increasingly interoperable, software-enabled and algorithmically controlled. The result is a huge jump in cybersecurity risks.

Last year, the chief information security officer of a leading U.S. research hospital told regulators his organisation has 25,000 connected devices in its facilities. These comprise 6,000 makes, models and versions with over 15 operating systems. Many of these devices operate as families or clusters of inter-operable devices and equipment. Every device is a snowflake. Keeping up with routine patches and upgrades is tough, not to mention urgent vulnerability mitigation.

Worryingly, some white hat hackers have observed that device-specific cyber-vulnerabilities could provide an entry point for lateral movement into a hospital’s IT systems, making real the possibility that a trauma centre could become a centre of trauma.

Regulators are keenly aware of the trade-off between these emerging technologies and the risks they present. For its part, the FDA now insists that medical device manufacturers step up their games when it comes to post-market surveillance and adverse event management. Under the EU MDR, heightened vigilance will be demanded from device manufacturers and distributors.

Overwhelmed and underfunded

Clinical engineers and medical technology specialists face huge challenges. They must track, monitor, and maintain growing volumes of increasingly complex medical devices and equipment across multiple delivery locations (e.g. acute care, community facilities and outpatient clinics, and home-based settings).

From beds, hoists and mattresses, infusion pumps, ventilators, flexible endoscopes, surgical instruments, radiation therapy and imaging equipment in an acute care setting to implants, closed-loop diabetes management systems and sensor-enabled asthma inhalers, the challenges in ensuring devices are safe and in good order at the point of care are huge.

Standoff over servicing

OEMs, hospital systems and third-party service firms disagree about who’s accountable. On a day to day basis, this standoff about qualifications, competence and contractual obligations for medical device servicing further complicates an exceedingly difficult operating environment.

Data, system and organisational silos

Silos reduce transparency and delay action when it matters most. Without necessary visibility and traceability, it’s difficult for hospital staff to assure that medical devices and equipment are safe and in good order.

Under-reporting of incidents and long supply chains delay action. It can take months or years for manufacturers to recognise and attribute adverse events to their devices. Even then, root cause investigations (e.g. design, production, component failure, training protocols) create further delays, leaving patients vulnerable to preventable injuries, complications and deaths.   

Healthcare analytics has the potential to help identify possible health risks, promote better health and deliver more accurate diagnosis and treatment plans. There are several challenges that must be overcome before healthcare can deliver on that promise.

Let’s first agree on the kind of healthcare analytics we are discussing. It’s a broad term and can mean different things to different people. In fact, companies have been performing some kind of healthcare analytics for years, primarily around revenue cycle and claims data. For purposes of this discussion, we are looking at predictive analytics that is the basis for real-time or near real-time decision support. This kind of analytics is still rare among healthcare organisations.

In fact, Heather Fraser from IBM’s Institute for Business Value, states that “many organisations say they have some kind of strategy for implementing predictive analytics, but most are not looking at it from an enterprise standpoint or as an enabler to corporate strategy.” This siloed approach will make it difficult for them to share information across the entire healthcare system if they can’t share within their four walls.

There are two levels to healthcare predictive analytics. The first one, or what could be considered the ‘low hanging fruit’, is using risk factors to determine a patient’s propensity for certain health problems. These are the one-to-one or two or three risk factors that may lead to the problem based on lifestyle, ethnicity, family history or health condition. For instance, if a person is a smoker there is strong evidence that they may develop lung cancer or cardiovascular disease. This kind of analysis is fairly easy and can usually be performed in most of the major EHR software solutions.

The second level is much more challenging. This is the kind of analysis that involves hundreds or thousands of patients with similar profiles and health conditions, which alerts the provider to the likeliness of a patient developing or having a particular health problem. The challenge here not only comes from incorporating all the other non-identifiable patient data, but also the volume of data that may be required for each patient. 

Additionally, at this point, no one really knows which data elements would be the most predictive. In other industries, you can start with a FICO score or life-stage or other segmentation and build upon that. In healthcare, we have several factors from demographics to healthcare condition, each with potentially hundreds of variables, which could be predictive. The computing power to manage this will be tremendous.

That leads to another challenge – the data warehouse. Most healthcare organisations are pretty weary from implementing and paying for their EHR solution, but that’s only the beginning of the technology transformation

The first level of healthcare predictive analysis are the one-to-one or two or three risk factors that may lead to the problem based on lifestyle, ethnicity, family history or health condition.

The next step is getting the clinical data from the EHR, the claims data, the operations data and ambulatory data into one place where it can be analysed. To some, this may sound easy, but the volume of structured and unstructured data, regularly extracted and loaded will be a huge burden for many. It is a level of data an order or magnitude that most people can’t comprehend. Fortunately, there are companies that help make the process a lot easier with data loading and analysis processes. They are usually able to scale their process to large and small healthcare organisations so that we don’t end up with the system of haves (large groups) and have nots (small groups).

This is not to say that predictive analytics for real-time decision support shouldn’t be pursued. Some companies like the ones I’ve previously mentioned as well as others are making some progress. Many organisations are already seeing some progress in predicting strokes, congestive heart failure and other health problems through their applications. This is not an overnight transformation; it is something that will take years. Whenever it gets here though, it will be a game-changer, which will help us all live a longer, healthier life.  

One of the UAE’s first specialist providers of 3D printed healthcare products, Sinterex recently made headlines when the company collaborated with the Dubai Health Authority (DHA) to use titanium 3D printing to save the jaw of a patient with a tumour. In an interview with Arab Health Magazine, Julian Callanan, Managing Director, Sinterex, shares how 3D printing is all set to revolutionise the healthcare industry.

Tell us about Sinterex. When was it established, how has the journey been?

Sinterex specialises in 3D printed medical products. We are a still a young business, in fact it was just over two years ago in February 2017 that we printed our first product. In this time though we have achieved some notable milestones. We were the first company to commercially deploy a metal 3D printer in the UAE and the first to 3D print teeth in the UAE.

We have seen a good measure of progress on the journey so far, but it has been by no means straight forward or easy. The machinery and equipment that we deal with are highly complex requiring strong technical knowledge. There is a lack of locally available materials or staff to support the type of work we are doing, so we have relied on international imports and invested in training our team. Furthermore, because we are leading with new technologies and concepts, we have had to educate the market about the benefits of our methodologies and then prove the performance over time.

How does the company’s product range help the healthcare industry?

What we do that is different to most other medical device manufacturing businesses is that all our products are completely patient specific, meaning that they are produced solely for one particular patient. This patient specific approach has benefits for the healthcare industry. It gives the patient a better solution for their problem, it supports the clinician with better diagnosis and comprehension of the patient’s situation, and it can save time and complexity during medical procedures.

Our current product range is split into three focus segments; Dental, Craniomaxillofacial, and Anatomical. Under the Dental market segment, we are 3D printing teeth and dentures, correcting misaligned teeth through 3D printed clear aligner treatments, and guiding implants to an accuracy of 0.5mm through 3D printed drill templates. For our Craniomaxillofacial customers, we are providing Virtual Surgical Planning to predict the outcome of a surgery before it starts, 3D printing bone cutting and drilling guides, and titanium 3D printing patient specific implants. For our Anatomical customers we are 3D printing parts of the anatomy such as hearts, kidneys, and vascular structures. 

What, according to you, is the impact of innovation in the delivery of healthcare?

With so much at stake, healthcare has and always will be a hotbed for innovation and invention. At the moment, 3D printing is one of the fastest developing emerging trends within healthcare. This is not to say that 3D printing will transform all of the healthcare industry. But in certain healthcare verticals, 3D printing, working hand-in-hand with digital planning software, is starting to really change how we approach and think about complex procedures.

Take knee replacements for example. Patients have traditionally been supplied with new knees ‘off-the-shelf’ with the surgeon choosing the best approximate size and design for the patient’s weight and lifestyle. Now, through the production efficiencies offered by 3D printing, it is possible to have a completely bespoke knee designed and produced, which considers the exact requirements of the patient. 

Tell us about your collaboration with the DHA in the recent case where a patient’s jaw was saved using 3D printing.

The patient, a 17-year-old girl in high school, was admitted to hospital after discovering she had a large, fast growing tumour of the right jaw. Unfortunately, due to the growth of the tumour, the jaw had to be partially removed. Our work involved supporting the surgeon, Dr. Khalid Ghandour, with the reconstruction of the jaw.

The workflow started with the patients CT scan, which was segmented and converted into a 3D printed physical model. This model allowed Dr. Ghandour, and his team of surgeons, to visually inspect the patient’s situation and to develop a treatment plan.

After finalising the treatment plan, we 3D printed a Surgical Guide, which was fitted to the patient in the operating theatre to ensure that the surgeons drilling, and cutting are guided with precision. Finally, a patient specific implant was 3D printed in bio-compatible medical grade titanium.

Could you shed light on your future plans.

In the short-term we are focused primarily on the UAE. This is our home market and we need to use the network and momentum we have here to deepen the quality of our current products whilst testing and developing new exciting concepts. That said, we already have an international customer base stretching from Saudi Arabia to South Africa, so we definitely see the potential for international expansion.

For future projects, we are working on some really exciting concepts around ‘Patient Experience’. I can’t say too much at this stage but hopefully in the next few months we will be able to share a new concept, which will change how patients and doctors view and interact with their data.

One year into their marriage, Jessica Blackford-Cleeton and her husband, Brandon Cleeton, were busy planning a future together. That included building their careers, having children and raising a family in Springfield, Illinois. However, cancer had a different plan for the couple.

It started with pain in Jessica’s lower abdomen – sometimes so severe that she twice landed in the emergency room. A CT scan showed a small spot on her abdomen. The subsequent biopsy revealed cancer, “and it was everywhere,” Blackford-Cleeton said.

Blackford-Cleeton was diagnosed with mesothelioma, a rare and aggressive cancer that affects the linings of organs. Mesothelioma most often affects the lungs, where it is linked to asbestos exposure.

Her cancer was in the lining of her abdomen (peritoneal mesothelioma). Only about 3,000 people are diagnosed with mesothelioma in the U.S. each year; peritoneal mesothelioma is even rarer, with just 500 to 800 cases a year.

“I was so scared,” Blackford-Cleeton remembered. “When I did research on the Internet, it was all grim and bad. I had very little hope.”

Also looking grim were the couple’s chances of having children, which they were trying to do at the time of her diagnosis.

“We thought, ‘Of course it isn’t going to happen,’ because the cancer was all over my ovaries,” Blackford-Cleeton said.

Her oncologist in Springfield referred her to the University of Chicago Medicine, where specialists at the Comprehensive Cancer Center have been dedicated to mesothelioma research and care for more than 25 years. Her care team included gastrointestinal oncologist and mesothelioma expert Hedy Kindler, MD, and surgical oncologist Kiran Turaga, MD.

“When we met with Dr. Turaga, we had so much more hope about the disease and how to move forward,” Blackford-Cleeton said. “We knew we would have a future at that point.”

Her treatment included surgery to remove the cancer, followed by a procedure called HIPEC (hyperthermic, or heated, intraperitoneal chemoperfusion), which targets and kills cancer cells that remain after surgery. HIPEC has fewer side effects than traditional chemotherapy because the medicine targets specific areas rather than circulating throughout the whole body. Also, the heated medicine causes blood vessels to expand, allowing the chemotherapy to penetrate deeper and more effectively.

Cleeton remembered his wife’s 14-hour procedure as being “one of the longest days of my life and probably the most terrifying.”

The surgical team successfully removed hundreds of tumors in Blackford-Cleeton’s body. They also removed an appendix, parts of her intestines and diaphragm, and an ovary. One ovary.

Going into surgery, Blackford-Cleeton and Turaga discussed the procedure’s potential impact on her fertility. “We talked about the fact that when we put heated chemotherapy inside her belly, it could change her life forever - especially her ability to have kids,” said Turaga.

She begged Turaga to save at least one ovary so she and her husband would have a chance to have a baby in the future. “He found a way,” Blackford-Cleeton said.

“When we met with Dr. Turaga, we had so much more hope about the disease and how to move forward,” Blackford-Cleeton said. “We knew we would have a future at that point.” 

One year after surgery, Blackford-Cleeton was cleared to begin in vitro fertilisation. In August 2017, the couple welcomed their son, Avery. Or, as the couple jokes, “Brandon’s mini-me.”

For three years, her test results have shown no evidence of tumors. “It is a testament to how much the body can endure,” Turaga said, calling Blackford-Cleeton’s story “remarkable.” “She reminds us every day of how vital she is, of how her spirit is so strong. Cancer can’t compete with the human spirit.”

Blackford-Cleeton finds strength from her support group, including her parents, who cared for her full-time while Brandon worked and often made the six-hour round-trip drive between Springfield and Chicago for her follow-up appointments. She also connected with new friends and resources through the Mesothelioma Applied Research Foundation.

Above all, she is grateful to Brandon for helping her navigate “a new normal” and taking on extra responsibilities.

“We had to switch roles from husband and wife to patient-caregiver, where he did 99 per cent of the work just because I couldn’t,” Blackford-Cleeton said. “It’s definitely a team effort, with him being the captain and the player.”

Meanwhile, Cleeton finds his motivation in his growing family: “That little boy’s smile certainly makes me want to jump up and go that extra mile,” he said. “If I feel like I don’t have a drop of energy left in me, he’s my motivator — and so is Jessica.”

“We took the vows for better or worse, in sickness and in health,” he added. “I feel like we just step up to the plate every day, make the best of it, and appreciate everything we have.”  

For more information, visit https://www.uchicagomedicine.org/global

Telerehabilitation (TR), which is the use of digital technologies to provide rehabilitation services from a remote location, a solution for the increasing demand being placed on the healthcare sector, constitutes a small part of the literature on telemedicine, with very few studies being reported in resource constrained countries.

The literature indicates that while telemedicine offers great opportunities to healthcare in general and for rehabilitation services, it could be particularly beneficial for resource constrained countries, where access to basic healthcare is compromised by lack of services and skilled professional care, by providing access to medical services in any part of the country or the world.

With an increase in the various disorders such as cerebro-vascular accidents, traumatic brain injury, developmental delays in paediatrics, etc., that require rehabilitation interventions like physiotherapy, occupational therapy, speech language pathology and the like in resource constrained countries, and considering their dearth, a new method such as TR needs to be considered for their intervention.

Despite increased reporting about TR research, many clinicians are still not using it, which may be due to the lack of knowledge, technical skills, understanding or its accessibility. Clinicians who have used video-conferencing, Skype, email and telephony for work have been driven by local need and the availability of infrastructure. TR has considerable potential in resource constrained countries to address the treatment gaps, but while this is theoretically feasible, attempts to implement it in public sector facilities have not been very successful.

In 2014, the Abu Dhabi Telemedicine Centre launched a round-the-clock telephone service that connects patients to nurses and doctors throughout the region. The Department of Health- Abu Dhabi currently has regulations setting minimum standards for telemedicine.

The Dubai Health Authority (DHA) has also taken an important step towards modernising the Emirate’s healthcare industry with the passing of Administrative Resolution No. 30 of 2017 concerning the Regulation of Telehealth Care Services (the “Telehealth Regulations”), which sets out minimum standards and requirements for the provision of telehealth services across Dubai. Consideration has to be given for health insurers and health maintenance organisations to cover the cost of healthcare services provided through telerehabilitation on the same basis as those provided through in-person visits, which can further supplement the implementation of TR.

Benefits of TR

The main benefit of TR is that treatment can now be accessed from patients’ homes or primary healthcare centres in remote areas. This is done by improved online infrastructure and increasing Internet connectivity or by making the country digitally empowered in the field of technology, with three core components of digital infrastructure, delivery of services digitally and digital literacy with increased connectivity in under-served areas with high-speed internet networks, which will make TR possible for people throughout a country.

In addition, treatment through this new mode has now become cost effective since it reduces the need for patients to travel to the hospitals to meet a physician or to a centre for various rehabilitation services. It is convenient for patients who experience constraints that affect their ability to travel. Another benefit is the continuity of care technology provides. The professional can access the patient from where he/she is and vice versa, if they are moving places within the country or outside the country. TR will be welcomed by patient and/or their caregivers as it will give them access to healthcare services that are not locally available, and which they might not otherwise have benefited from. Parents will feel empowered while doing speech language therapy through TR and will want to learn and interact more during the sessions.

Technology used

Skype or other applications such as Hangout and Facetime on iPhone are the most commonly used internet applications used by TR personnel. However, there are many TR platforms (video-conferencing space that allows a professional to host a session) available in business in the U.S. and also various companies that specialise in providing TR.

Challenges of TR

One of the major concerns that have emerged in relation to telemedicine in general, is the potential risk associated with the digital transmission of patient records. As such, creating reliable safeguards for the protection of sensitive patient data was one of the primary objectives for introducing a modern legal framework. Accordingly, there needs to be adequate measures taken by telemedicine and TR care providers to ensure the protection of patient data and privacy.

Another issue is if TR will be accepted by other professionals. It has been identified that service provision through TR was not widely accepted by health professionals in some countries. One main reason was that a physician would not want to liaise with another, which may be due to professional rivalry as well as a lack of awareness regarding its effectiveness.

Concerns over the severity of a patient’s condition are evident, which can affect the effectiveness of TR. Paediatric cases with attention deficit or poor eye contact posed a challenge using TR; however, a trained aide can be used at the site of the patient to assist in such situations. The most common issues faced during TR sessions can be power failures, low bandwidth and poor Internet connectivity, with power outages in resource constrained countries. While remote TR personnel may have good Internet connectivity and no power failures, this may not be the case for the patient. This is compounded by old devices, such as the laptop or a personal computer, which can hinder the audio-visual clarity at both ends. In addition, the computer literacy of patients and caregivers can also pose as a challenge.

Treatment through this new mode has now become cost effective since it reduces the need for patients to travel to the hospitals to meet a physician or to a centre for various rehabilitation services.  

TR in education

To successfully implement TR in a resource constrained country, there needs to be awareness of TR and its scope of practice. As in many such countries, the academic teaching departments are largely unaware of TR. It provides new ways to assist rehabilitation skill development – supporting ongoing learning for students and clinicians working with patients.

TR guarantees exposure to certain experiences and also aids non-technical skills training, which is an opportunity to build confidence. It can help overcome challenges of workplace isolation, such as lack of on-site mentors, limited local professional development and lack of local available cases for advanced learning and practice. It provides opportunity for massed and varied repetition, reflective practice and interdisciplinary learning. But this requires trained users to ensure optimisation of use and workplace change and investment in required technology.

A good government infrastructural support appears to be the main element influencing the effectiveness of a new intervention system such as TR. The major constraints in infrastructure could be the political and regulatory risks such as formulating government level rules and regulations to govern TR services, which would lead to its streamlining and obstacles to access financing or funding. Nevertheless, TR seems to be the future and one of the most innovative solution for the growing needs for rehabilitation services.

Investing in healthcare, including hospitals, insurers and MedTech firms, make for excellent “all weather” investments i.e. investments that achieve capital gains in all types of investing environments. Fundamental forces have long made healthcare such a compelling investment: an ageing population, the rising prevalence of chronic disease, the continuous development of innovative drugs and devices, and a still fragmented delivery system that is ripe for innovation, disruption and consolidation.

The population of the GCC region is estimated to jump by 6.6 million to 61.6 million people, 17 per cent of whom will be 50 years old and above, by 2022. This will exert pressure on the existing healthcare system, and therein lies the opportunity for healthcare companies to rapidly scale up their offerings and meet the demand.

Healthcare expenditure in the Middle East amounted to US$76.1 billion (AED279.5 billion) in 2017 and is expected to reach US$104.6 billion (AED384.2 billion) in 2022, according to a report by Alpen Capital. In the GCC region, healthcare spend is projected to rise by 6.6 per cent year-on-year – faster than the global average – with the UAE forecast to account for 25 per cent of this growth by 2022. Unsurprisingly, the region is attracting attention from industry leaders, investors and corporate buyers globally.

Strong fundamentals

Historically, the governments of the GCC have provided strong leadership in continuing to evolve the provisioning of healthcare services in the GCC to address gaps in supply and quality. However, many governments have come to realise that continued heavy investment in healthcare is an economic ordeal, as costs continue to outpace GDP. In times when sustainable investment opportunities are limited, new avenues are always welcome.

The UAE and Saudi Arabia are likely to dominate the sector with a projected combined share of over 80 per cent of the regional healthcare expenditure in 2022. The governments of the two countries have demonstrated their intent to improve their respective healthcare spaces in their national transformation plans, the UAE Vision 2021 and the Saudi Vision 2030, respectively. This top-down focus on healthcare has provided an impetus for growth. Government programmes ranging from public private partnerships to regulations are designed to foster the inclusion of private sector providers to both relieve the burden on the public sector and become a source of diversification and growth of a knowledge-based economy.

Risks and returns  

The intensifying public discussion on healthcare and the complex web of regulations across the region make it a challenging investment field. Investors cannot go in blindly – they require a technical understanding of the scientific and regulatory developments in the respective markets.

In a high-valuation environment, investors and PE funds can’t rely on multiple expansion alone to generate returns. When funds can execute a credible plan for margin growth immediately after they acquire a target, they can create a virtuous cycle of value creation.

Apart from playing the long game, investing in the healthcare space is also not completely about returns. Certain investments could fall under impact investing – that is, investing in companies, organisations or funds with the intention to generate measurable social or environmental benefits in addition to financial returns.

As indicated by the earnings per share growth across the sector in the region, which currently stands at 24 per cent, healthcare is poised to remain a high-yield investment domain. Historically, stocks in the sector have performed favourably in the regional indices, recording an average return of double digit returns over a multi-year period.  

When funds can execute a credible plan for margin growth immediately after they acquire a target, they can create a virtuous cycle of value creation.

The exit opportunity  

Identifying the right time to exit is the cornerstone of any investment strategy. Traditionally, private equity firms have made way for corporate buyers and other healthcare groups seeking expansion, whether geographical or sectoral.

For instance, the acquisition of Abu Dhabi-based Al Noor Hospitals Group by South Africa’s Mediclinic in 2015 boosted underlying revenues to AED1.77 billion in one year, representing a 35.54 per cent growth. Similarly, NMC Health acquired a 70 per cent stake in CosmeSurge and related businesses for US$170 million from Emirates Healthcare Group, and an 80 per cent stake in Riyadh-based Al Salam Medical Group for US$37 million.

Keeping an eye on the growing consolidation will enable funding institutions to diversify their investments across the sector, thus staying relevant and competitive.

References available on request.

Conventional wisdom for capitalising on telehealth suggests joining forces, partnering, and acquiring innovative practice groups to create leading edge mergers and start-ups.

“Invest in innovative technologies where systems own a piece of a technology platform. This enables the organisation to have a say in the software development and ensures that it is customised to their needs. As a result, organisations are showing ROI and not an ongoing expense for payment of subscription fees,” says Christopher J. Donovan in Telemedicine Investors Roundtable Focuses on Progress, Barriers, and ROI, Health Care Law Today Blog.

What if any investment in buying or creating new technology was prerequisite to occupying a prime seat in the radical overhaul of how healthcare will be conducted? What if the move was to simply utilise social media to transform healthcare by employing what are ordinary and commonplace communication platforms for most people?

Consider the February 2019 acquisition of asynchronous provider Sherpaa Health by synchronous provider group Crossover Health. Joining forces, partnering, acquiring practice groups like Sherpaa present opportunities for mergers and start-ups.

Investment opportunities in telemedicine/telehealth’s past have faced a steep uphill climb. Over the past two decades, the more radical the change in how healthcare might be conducted the steeper the slope to adoption by legacy healthcare entities. That hill is flattening out. More opportunities with a corresponding rise in entirely new healthcare models are presenting themselves. One of the most transformative new treatment models is asynchronous care.

Asynchronous care

“Asynchronously means in which the patient and the clinician need not be communicating at the same time. This contrasts with synchronous technologies, in which patient and clinician must communicate at the same time,” says Chan, Torous, Gratzer, Yellow from Curr Psychiatry Rep. 2018 Aug Review of Use of Asynchronous Technologies Incorporated in Mental Health Care.

The definition is simple. The understanding is seismic. The patient and the physician communicate with each other without speaking or otherwise communicating simultaneously. To be simple and clear, interaction between the provider and the patient can take place at different times using platforms exactly like those that are commonplace in social interaction: texting, Instagram, websites, Facebook, Tumblr…you get the picture.

Two companies currently reaping the financial benefits by fully embracing asynchronous communication are Crossover Health and Sherpaa Health. Both are located in the U.S. Crossover Health is located in San Clemente, California, and was founded in 2019. They design and deliver membership based primary health care services to self-insured employers. Built on non-fee for-service business model, it serves some big-name large employers such as Apple and Facebook. Crossover purchased Sherpaa in February 2019.

The Sherpaa Health platform was developed by Jay Parkinson, MD, in 2012. Using text, Sherpaa delivered healthcare consultations to subscribers using asynchronous communication between patients and providers.

The Crossover Health model has been widely adopted across many providers and insurers. It is commonplace for established provider groups and insurers to provide a web portal so that the insured and the provider may communicate about appointments, lab reports, patient requests and patient/MD feedback. The new acquisition signals the newest model in delivering services, “in person, online and anytime,” a report in Cision PR Newswire highlighted.

“The ability to leverage the trust achieved by Crossover Health in its physical health centre model, and seamlessly to extend that trust through the digital practice capabilities of Sherpaa, creates a singular care delivery vehicle able to offer primary care anywhere,” says Dr. Parkinson, Founder of Sherpaa Health.

Challenges

Telemedicine/telehealth has used asynchronous models for decades by taking advantage of the ability to transfer images over the web. For example, any service that relies on imaging such as dermatology, ophthalmology, radiology has benefited from posting media to secure platforms. A “charting” module often accompanied the image so the physician could make notes and grade severity. Since the early 1990s such was considered a radical up ahead of the mainstream; long before Facebook, Instagram and similar popular and standard communication platforms took over daily lives. The jump to conducting primary care communication, however, via apps, messaging, and SMS presents a move towards embracing the social mainstream.

A big hurdle in investing in telehealth/telemedicine in the past was that in the minds of providers and payors; telemedicine platforms targeted patients and providers in remote areas, “distant” medicine. Investment meant funding sufficient Internet bandwidth – the “pipeline” – that was often absent. More costs without the returns was an inhibitor. The Sherpaa and Crossover team demonstrates that having to deliver health services remotely is not the main consideration. SMS and phone apps can be used effectively by healthcare companies. Parkinson has stated that 70 per cent of health concerns can be treated under the Sherpaa asynchronous model. Synchronous communication is no longer essential to provide quality care.

Opportunities

A current opportunity for investment in this model comes with the announcement by the Centers for Medicare & Medicaid Services (CMS). As the single largest payer for healthcare in the U.S., anything (CMS) does to expand payments to new technologies is seismic.

“Telehealth/Telemedicine services can be billed by code HCPCS code G2010, which outlines reimbursement for “remote evaluation of recorded video and/or images submitted by an established patient.” HCPCS G2012 outlines reimbursement for “brief communication technology-based service, e.g. virtual check-in.” George McLaughlin sees this new CMS policy stimulating telemedicine and remote patient monitoring which, he believes, will skyrocket in 2019.

The jump to conducting primary care communication via apps, messaging, and SMS presents a move towards embracing the social mainstream.

Investing in sectors of healthcare

Globally, the most likely sectors in which healthcare groups should invest are “behavioural health, post-acute care, senior housing and chronic care management…all areas expected to see significant growth in telemedicine.”

These are the medical domains which will attract asynchronous care because these do not require real time responses. Parkinson realised this in 2012. Seven years later his company – and his idea – were bought out. He is now the Chief Designer at Crossover Health.

Conclusion

As early as 2017, the UAE’s telehealth investment strategy was to begin with on demand or synchronous care and with time a solid foundation to expand to asynchronous care. Also, a different combination of payment models was offered such as membership or pay as you go.

For instance, HealthatHand offers patient to doctor video consultations. Founded in 2016 and based in UAE, Founder and CEO Charlie Barclay says, “unlike the U.S. or other international markets, the Middle East’s telehealth landscape is relatively immature in terms of both regulation and competition.”

A partnership of established healthcare such as Abu Dhabi Telemed Centre, and the Swiss tech company Medgate became a powerful trio by accepting the UAE’s leading private insurance Daman Health.

It is beautiful to see the myriad of possibilities in telehealth’s asynchronous care model. Why be limited by the Uber on demand model while there is a common market that waits, and needs the care minutes, days or when they desire later. Not at this second.

Opportunity abounds in merging readily available models by merging them with established healthcare and a good digital platform that not only streamlines but accelerates the service delivery without having to be remote, on demand, or just privately paid for as in the past.

Will your healthcare investment become the next Crossover/Sherpa, myhealthathand.com or Abu Dhabi Telemed Centre/Medgate success story?

References available on request.

As our world becomes increasingly connected to the Internet, more citizens using these technologies are relying upon them daily. Whether we use our smartphone to summon a taxi, reserve a flight, book that last-minute accommodation, manage our finances, order food, purchase a bestseller, search for our soul mate, apply for a job or claim fame through a self-made video channel, no matter where we are globally none of us can deny that the Internet has changed our lives. This is the age of digital consumerism. We are all becoming ever-demanding digital consumers who expect more from our service providers than ever before and who can manage almost every aspect of our daily lives on a phone.

The question is, “Could digital consumerism have an impact on the way we manage our health?” Consumer technologies can and are already benefiting healthcare in numerous ways. A valuable example is telemedicine platforms where patients and doctors use video to consult virtually, saving them both time and money as well as the heavy burden of travel for the sick patient. 

Telehealth can also be a means to reduce congestion in overcrowded health facilities. In low-to-middle income countries (LMICs) this is particularly important in rural areas where the distance to travel to a hospital can take hours, if not days. A further example is the development of health-specific platforms, which curate resources for patients. These resources could include disease education, patient communities or tools to track their condition.

One such example is www.inspire.com, which offers a much more controlled environment for patient groups to network compared to public websites like Facebook. Considering the dynamics of searching for reliable, fragmented medical information on the web, platforms like Inspire also empower patients by providing them with access to content much faster because it is curated in a central place.

The first website, Tim Berners-Lee’s description of the World Wide Web project, went public 28 years ago on August 6, 1991, and as the web expanded globally it gave patients access to a plethora of medical information. The latest estimates from organisations such as the International Telecommunications Union (ITU) suggest there are now 3.2 billion people using the Internet in 2019. This caused some chaos in healthcare as patients began to self-diagnose or question their doctor’s opinion often based upon dubious information. Because of this phenomenon, the term cyberchondriac was coined, which was a combination of two words: “cyber and hypochondriac” as then documented in the Oxford Dictionary during this era in the 1990’s. The idea of patients having access to medical data online was disputed for years afterwards and continues today almost three decades later, even though technology is improving for patient empowerment exponentially. 

Evolution of the e-patient

Whilst the world wide web is still populated with both accurate and inaccurate content, otherwise known as “fake news”, modern e-health innovators are providing online solutions that address the quality of information and tools patients use. The medical web is becoming more sophisticated and will continue to do so along with patients who are using them. Would it make sense then to continue classifying every digital patient as a cyberchondriac? Dismissing the data that they collect electronically, especially when these types of Internet connected devices extend to wearables and mobile applications, which they engage with daily? Connected devices that transfer data back to their Electronic Health Records (EHRs) so their medical providers can make more informed decisions? Telling these patients to stop collecting data because they are cyberchondriacs would be counterproductive to e-health.

Many alternative terms have been used to explain digital patients since the emergence of the word cyberchondriac, which include patient 2.0, but theoretically this only describes the type of web technologies the patient is using, which in this circumstance is web version 2.0. During the next generation of the web (web 3.0), that would evolve to the term patient 3.0. It doesn’t describe this digital health citizen in terms of the many other dynamics required for good health outcomes, including the behaviour of the patient and relationship with their care providers, which has been a cornerstone of practicing modern medicine for centuries.

In 1999, a few short years after the word cyberchondriac emerged, the term e-patient was coined by Tom Ferguson, MD, to describe individuals who were equipped, evaluating, enabled, educated, empowered and engaged in their health and healthcare decisions. He began work on a white paper, commissioned by the Robert Wood Johnson Foundation to describe this phenomenon. During his research, he documented how patients were using the Internet to empower themselves. He also categorised them into different patient population groups based on varying criteria, which considered factors like their digital divides and medical circumstances, which affected the way they participated online. Never had such an in-depth study been conducted.

Whilst Dr. Ferguson had defined healthcare consumerism as a means to improve medicine using technology, he believed e-patients could further partner with their healthcare providers in various ways including through medical research and shared-decision making. He believed that recognising this new digital stakeholder as an equal partner in the system was important to improving health outcomes and the future of digital medicine.

e-patients could further partner with their healthcare providers in various ways including through medical research and shared-decision making.

In the real world, consumerism has been defined in different ways including that it is a social and economic order that encourages the purchase of goods and services in ever-greater amounts and it generally only values the interests of the buyer (i.e. consumer). In this digital age, people are exposed to mass consumerism and product placement in the media or even in their daily lives. The line between information, entertainment, and promotion of products has been blurred so people are more reformulated into consumerist behaviour. Therefore, something to consider is whether calling a recipient of healthcare a ‘consumer’ as opposed to a ‘patient’ could have distinct connotations and therefore result in differential behaviour.

Whilst healthcare can learn from these digital consumer trends, the e-patient concept helps to ground those consumerism ideologies. For example, many platforms are developed with very limited consideration for what the patient truly needs and therefore, some leading organisations including pharmaceutical companies have created partnerships with patients to co-create their innovations and in doing so have been able to deliver more meaningful solutions.

Such an example is the ‘Speak your Migraine’ platform, developed in partnership with Novartis Europe and patient groups, which also offers a mobile application to track migraines. Whilst consumerism is heavily focused on all the “bells and whistles”, “the faster, the bigger, the cheaper, the better”, patient empowerment is focused more critically on meeting the patient’s individual human needs. E-patients are not about consumer-centred innovation, it is about patient-centred innovation, and that’s far more personal. Going back to the question then, “Could digital consumerism have an impact on the way we manage our health?”

As an e-Patient activist and from a personal perspective I would say yes, consumerism can teach us lessons as healthcare enters digital transformation, but I think we shouldn’t lose sight of what we have achieved as human beings in modern-medicine before trying to commercialise and industrialise it completely.  

The evidence on the effectiveness of a low carbohydrate, high fat or ketogenic diet as an effective treatment for Type 2 Diabetes is gaining ground and regularly being documented in both peer reviewed studies and personal accounts.

However, the incidents of Type 1 Diabetics using the diet to live a life far less dependent on insulin and with the capacity to manage their own medication, health and weight with ease are also increasing. Almost too good to be true, surely?

In fact, there is a doctor practicing right here in the Gulf who has lived this experience himself. He now spends his time both treating patients and spreading the word of his own personal lived and ongoing success throughout the world, in order for two things to begin to occur. For other diabetics like himself to realise this solution and no longer be a slave to medication and for the doctors who so readily prescribe it to sit up, take note, and realise that their patients don’t have to end up with nerve damage, on dialysis, with amputations, or blindness. There is another way.

Success story

Dr. Ali Irshad Al Lawati’s story started when he was seven years old and diagnosed with Type 1 diabetes. His parents followed the doctor’s advice and treated him with insulin and a low-fat, high-carb diet as prescribed. By the time he was 15 years old, carrying all the extra weight the excess insulin had encouraged, Dr. Ali noticed that one of his grandfather’s friends who had previously been extremely overweight with many health complaints and severe pain, had lost the weight, looked years younger and was smiling for the first time in years. He asked the man what he had done, and was handed a pamphlet on the low-carb, high fat diet (keto).

Of course, he was at first extremely sceptical and believed his grandfather’s friend was playing a risky game with his health. However, the more he researched it, the more convinced of the diet’s healthfulness and power he became.

He visited endocrinologist after endocrinologist, and (this being 17 years ago, although it could very well be today) every one of them told him this was an extremely dangerous path to follow and he would end up dying of heart disease before his T1D killed him.

Not to be dissuaded, he was so convinced by his research and desperate to lose the excess weight that he chose to do this alone. He followed the guidelines as he had understood them from the studies he found. His results were outstanding.

He started with HBA1C readings around 8/9 per cent, on a daily dose of insulin of 84iu. His blood glucose values were completely erratic, and he suffered frequent hyper and hypo glycaemic episodes, making his life almost unmanageable. He also had the first signs of nephropathy in the form of proteinuria for two full years and compromised kidney function.

As soon as he began the low carb diet, he reduced his insulin dose. Initially by half, and within three months to a total daily dose of 30iu. His HBA1C reduced to 6 and eventually to a solid and safe 5. Within five months of doing keto, his proteinuria entirely disappeared, and his weight loss continued, leaving him at a healthy weight for his age and height.

He will always be a T1D, but he is no longer a slave to his blood glucose. His lifestyle and overall health have dramatically improved, as well as his self-confidence. All because he took the time to do his own research, read the mounting science and handled his health with wisdom rather than pills and needles.

Within five months of doing keto, his proteinuria entirely disappeared, and his weight loss continued, leaving him at a healthy weight for his age and height.

Dietary intervention

During his residency training he was able to travel to the U.S. to study with Dr. Bernstein, the leader in the field on this dietary approach to Type 1 Diabetes. Dr. Bernstein’s works include Dr Bernstein’s Diabetes Solution, The Diabetes Diet, Diabetes Type 2: Living a Long, Healthy Life Through Blood Sugar Normalization, Diabetes: The Glucograf Method for Normalizing Blood Sugar. He was also fortunate to study with Dr. Eric Westman, a giant in documented science and peer reviewed studies on the power of the low carb/keto approach to reversing T2D and managing T1D, and founder of the HEAL Clinics in the U.S. He also co-authored The New Atkins for a New You with Drs Phinney and Volek, and more recently Keto Clarity with Jimmy Moore.

Carbohydrate restriction is easily grasped by patients: because carbohydrates in the diet raise the blood glucose, and as diabetes is defined by high blood glucose, it makes sense to lower the carbohydrate in the diet.

 “By reducing the carbohydrate in the diet, we have been able to taper patients off as much as 150 units of insulin per day in 8 d, with marked improvement in glycaemic control-even normalisation of glycaemic parameters,” Dr. Westman has been quoted saying.

Armed with this invaluable experience, Dr. Ali returned to Oman to complete his internal medicine specialty and has since opened the Lifestyle Clinic where he is able to advise patients with conditions such as T2D, T1D, epilepsy, and Alzheimer’s on a dietary intervention that is changing their lives.

He has had some incredible successes; in fact all his T1 and T2 patients have reduced their medications and improved their quality of life. However, he does note how regretful it is that in terms of completely reversing T2D, the most success is seen when there is early dietary intervention, before the disease has had enough time to do lasting damage to the body.

Dr. Ali is living the quote he keeps on his wall by Thomas Edison: “The doctor of the future will give no medicine but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.”